Emphysema Nursing Care Plan & Management

Notes

Description

Emphysema is the enlargement and destruction of the alveolar, bronchial, and bronchiolar tissue with resultant loss of recoil, air trapping, thoracic overdistention, sputum accumulation, and loss of diaphragmatic muscle tone.

These changes cause a state of carbon dioxide retention,hypoxia, and respiratory acidosis.

Causes

The actual cause of emphysema is unknown. Risk factors for the development of emphysema include cigarette smoking, living or working in a highly polluted area, and a family history of pulmonary disease. Frequent childhood pulmonary infections have been identified as a cause of bronchiectasis.

Assessment

Anorexia, fatigue, weight loss

Feeling of breathlessness,cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea.

Diagnostic Evaluation

Medical Management

The major goals of medical management are to improve quality of life, slow progression of the disease, and treat obstructed airways to relieve hypoxia. Treatment is directed at improving ventilation, decreasing work of breathing and preventing infection.

Treatment of infection (antimicrobial therapy at the first sign of respiratory infection)

Oxygenation in low concentrations for severe hypoxemia.

Pharmacologic Intervention

Bronchodilators: Anticholinergic agents such as atropine sulfate, ipratropium bromide are used in reversal of bronchoconstriction.

Bronchodilators: Beta2-adrenergic agents such as( inhaled beta2-adrenergic agonists by metered-dose inhaler (MDI) such as albuterol, metaproterenol, or terbutaline )are used in reversal of bronchoconstriction

Systemic corticosteroids such as methylprednisolone IV; prednisone PO is used to decrease inflammatory response and improve airflow in some patients for a few days during acute exacerbations

Other Drug Therapy: Bronchodilators, which are used for prevention and maintenance therapy, can be administered as aerosols or oral medications. Generally, inhaled anticholinergic agents are the first-line therapy for emphysema, with the addition of betaadrenergic agonists added in a stepwise fashion. Antibiotics are ordered if a secondary infection develops. As a preventive measure, influenza and pneumonia vaccines are administered.

Nursing Interventions

Maintaining a patent airway is a priority. Use a humidifier at night to help the patient mobilize secretions in the morning.

Encourage the patient to use controlled coughing to clear secretions that might have collected in the lungs during sleep.

Instruct the patient to sit at the bedside or in a comfortable chair, hug a pillow, bend the head downward a little, take several deep breaths, and cough strongly.

Place patients who are experiencing dyspnea in a high Fowler position to improve lung expansion. Placing pillows on the overhead table and having the patient lean over in the orthopneic position may also be helpful. Teach the patient pursed-lip and diaphragmatic breathing.

To avoid infection, screen visitors for contagious diseases and instruct the patient to avoid crowds.

Conserve the patient’s energy in every possible way. Plan activities to allow for rest periods, eliminating nonessential procedures until the patient is stronger. It may be necessary to assist with the activities of daily living and to anticipate the patient’s needs by having supplies within easy reach.

Refer the patient to a pulmonary rehabilitation program if one is available in the community.

Patient education is vital to long-term management. Teach the patient about the disease and its implications for lifestyle changes, such as avoidance of cigarette smoke and other irritants, activity alterations, and any necessary occupational changes. Provide information to the patient and family about medications and equipment.

Encourage the patient to plan rest periods around his or her activities, conserving as much energy as possible.

Arrange for return demonstrations of equipment used by the patient and family. If the patient requires home oxygen therapy, refer the patient to the appropriate rental service, and explain the hazards of combustion and increasing the flow rate without consultation from the primary healthcare provider.

Exam

MSN Exam for Emphysema (PM)

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Question 1

Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

A

Asthma

B

Adult respiratory distress syndrome (ARDS)

C

Chronic obstructive bronchitis

D

Emphysema

Question 1 Explanation:

Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema.

Question 2

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:

A

1 L/min

B

2 L/min

C

10 L/min

D

6 L/min

Question 2 Explanation:

Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

Question 3

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

A

Report the finding to the physician immediately.

B

Measure the patient’s pulse oximetry.

C

Record the observation.

D

Apply a compression dressing to the area.

Question 3 Explanation:

Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Question 4

Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women?

A

Squamous cell carcinoma

B

Small cell carcinoma

C

Large cell carcinoma

D

Adenocarcinoma

Question 4 Explanation:

Adenocarcinoma presents more peripherally as peripheral masses or nodules and often metastasizes.

Question 5

The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

A

It increases inspiratory muscle strength.

B

It helps prevent early airway collapse.

C

It decreases use of accessory breathing muscles.

D

It prolongs the inspiratory phase of respiration.

Question 5 Explanation:

Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

Question 6

Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

A

Respiratory rate of 22 breaths/minute

B

Dilated and reactive pupils

C

Heart rate of 100 beats/minute

D

Urine output of 40 ml/hour

Question 6 Explanation:

In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Question 7

A lung transplant is the only way to slow the progression of emphysema.

A

True

B

False

Question 7 Explanation:

Smoking cessation, pulmonary rehabilitation, adopting a healthy lifestyle, and prescription drug therapy are all ways to slow the progression of emphysema.
Incorrect

Question 8

The inhalation of environmental air pollutants in the #1 cause of emphysema cases.

A

True

B

False

Question 8 Explanation:

Smoking is the #1 cause of emphysema

Question 9

Once diagnosed with emphysema, the disease state is constant.

A

True

B

False

Question 9 Explanation:

The disease state is progressive. Even though it cannot be stopped it can be slowed with treatment.

Question 10

Which of the following is the most important risk factor for development of Chronic Obstructive Pulmonary Disease?

A

Genetic abnormalities

B

Occupational exposure

C

Air pollution

D

Cigarette smoking

Question 10 Explanation:

Pipe, cigar and other types of tobacco smoking are also risk factors. While a risk factor, occupational exposure is not the most important risk factor for development of COPD. Air pollution is a risk factor for development of COPD, but it is not the most important risk factor. A deficiency of alpha-antitrypsin is a risk factor for development of COPD, but it is not the most important risk factor.

Question 11

Emphysema can be cured.

A

False

B

True

Question 11 Explanation:

There is no cure but the symptoms can be treated and progression of the disease can be slowed.

Question 12

A person with emphysema will not exhibit noticeable symptoms.

A

False

B

True

Question 12 Explanation:

They will exhibit symptoms including chronic cough, loss of appetite, fatigue, shortness of breath, excessive mucous production, wheezing, and blue tinting of the skin.
Incorrect

Question 13

Emphysema is described as:

A

A disease that results in a common clinical outcome of reversible airflow obstruction.

B

A disease of the airways characterized by destruction of the walls of overdistended alveoli.

C

The presence of cough and sputum production for at least a combined total of two or three months in each of two consecutive years.

D

Chronic dilatation of a bronchus or bronchi

Question 13 Explanation:

Emphysema is a category of COPD.

Question 14

Carbon monoxide is the waste product expelled from the body when you breathe out.

A

True

B

False

Question 14 Explanation:

Carbon dioxide is the waste product, not carbon monoxide

Question 15

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?

A

Venturi mask

B

Catheter

C

Non-rebreather mask

D

Face tent

Question 15 Explanation:

The non-rebreather mask provides high oxygen concentration but is usually poor fitting. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration.

Question 16

A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?

A

Increase the client’s oxygen flow rate.

B

Encourage the client to perform pursed lip breathing.

C

Check the client’s temperature.

D

Assess the client’s potassium level.

Question 16 Explanation:

Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.

Question 17

Air flows through the trachea into the left and right bronchi upon inspiration.

A

False

B

True

Question 18

Emphysema is not linked to which of the following terms?

A

Liver cirrhosis

B

Tachycardia

C

Dyspnea

D

Blue Bloater

Question 19

A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations?

A

Emphysema

B

Bronchial asthma

C

Bronchial asthma and bronchitis

D

Chronic obstructive bronchitis

Question 19 Explanation:

The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as “barrel chest.” The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

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Nursing Care Plan

Emphysema, Asthma and Chronic Bronchitis are disease under COPD. This NCP covers the emphysema and the other two COPD diseases.

Nursing Interventions

Rationale: Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds such as scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).

Rationale: Tachypnea is usually present to some degree and may be pronounced on admission or during stress or concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.

Note presence and degree of dyspnea as for reports of “air hunger,” restlessness, anxiety, respiratory distress, use of accessory muscles. Use 0–10 scale or American Thoracic Society’s “Grade of Breathlessness Scale” to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.

Rationale: Respiratory dysfunction is variable depending on the underlying process such as infection, allergic reaction, and the stage of chronicity in a patient with established COPD. Note: Using a 0–10 scale to rate dyspnea aids in quantifying and tracking changes in respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus.

Assist patient to assume position of comfort (elevate head of bed, have patient lean on overbed table or sit on edge of bed).

Rationale: Elevation of the head of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

Keep environmental pollution to a minimum such as dust, smoke, and feather pillows, according to individual situation.

Rationale: Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode.

Encourage abdominal or pursed-lip breathing exercises.

Rationale: Provides patient with some means to cope with or control dyspnea and reduce air-trapping.

Rationale: Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.

Rationale: Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm.

Monitor and graph serial ABGs, pulse oximetry, chest x-ray.

Rationale: Establishes baseline for monitoring progression or regression of disease process an complications. Note: Pulse oximetry readings detect changes in saturation as they are happening, helping to identify trends before patient is symptomatic. However, studies have shown that the accuracy of pulse oximetry may be questioned if patient has severe peripheral vasoconstriction.

Desired Outcomes

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range and be free of symptoms of respiratory distress.

Participate in treatment regimen within level of ability/situation.

Nursing Interventions

Assess and record respiratory rate, depth. Note use of accessory muscles, pursed-lip breathing, inability to speak or converse.

Rationale: Useful in evaluating the degree of respiratory distress or chronicity of the disease process.

Elevate head of bed, assist patient to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep-slow or pursed-lip breathing as individually needed or tolerated.

Rationale: Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase Pao2.

Rationale: Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation.

Rationale: During severe, acute or refractory respiratory distress, patient may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being.

Evaluate sleep patterns, note reports of difficulties and whether patient feels well rested. Provide quiet environment, group care or monitoring activities to allow periods of uninterrupted sleep; limit stimulants such as caffeine; encourage position of comfort.

Rationale: Patient in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medications. In addition, many COPD patients habitually eat poorly, even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, patient often is admitted with some degree of malnutrition. People who have emphysema are often thin with wasted musculature.

Nursing Interventions

Explain and reinforce explanations of individual disease process. Encourage patient and SO to ask questions.

Rationale: Decreases anxiety and can lead to improved participation in treatment plan.

Instruct and reinforce rationale for breathing exercises, coughing effectively, and general conditioning exercises.

Rationale: Pursed-lip and abdominal or diaphragmatic breathing exercises strengthen muscles of respiration, help minimize collapse of small airways, and provide the individual with means to control dyspnea. General conditioning exercises increase activity tolerance, muscle strength, and sense of well-being.

Stress importance of oral care and dental hygiene.

Rationale: Decreases bacterial growth in the mouth, which can lead to pulmonary infections.

Rationale: Decreases exposure to and incidence of acquired acute URIs.

Discuss individual factors that may trigger or aggravate condition (excessively dry air, wind, environmental temperature extremes, pollen, tobacco smoke, aerosol sprays, air pollution). Encourage patient and SO to explore ways to control these factors in and around the home and work setting.

Rationale: These environmental factors can induce or aggravate bronchial irritation, leading to increased secretion production and airway blockage.

Review the harmful effects of smoking, and advise cessation of smoking by patient and SO.

Rationale: Cessation of smoking may slow or halt progression of COPD. Even when patient wants to stop smoking, support groups and medical monitoring may be needed. Note: Research studies suggest that “side-stream” or “second-hand” smoke can be as detrimental as actually smoking.

Provide information about activity limitations and alternating activities with rest periods to prevent fatigue; ways to conserve energy during activities (pulling instead of pushing, sitting instead of standing while performing tasks); use of pursed-lip breathing, side-lying position, and possible need for supplemental oxygen during sexual activity.

Rationale: Having this knowledge can enable patient to make informed choices or decisions to reduce dyspnea, maximize activity level, perform most desired activities, and prevent complications.

Instruct patient and SO in use of NIPPV as appropriate. Problem-solve possible side effects and identify adverse signs and symptoms (increased dyspnea, fatigue, daytime drowsiness, or headaches on awakening).

Rationale: NIPPV may be used at night or periodically during day to decrease CO2 level, improve quality of sleep, and enhance functional level during the day. Signs of increasing CO2 level indicate need for more aggressive therapy.

Instruct asthmatic patient in use of peak flow meter, as appropriate.

Rationale: Peak flow level can drop before patient exhibits any signs and symptoms of asthma during the “first time” after exposure to a trigger. Regular use of the peak flow meter may reduce the severity of the attack because of earlier intervention.

Rationale: These patients and their SOs may experience anxiety, depression, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Support groups or home visits may be desired or needed to provide assistance, emotional support, and respite care.

Refer for evaluation of home care if indicated. Provide a detailed plan of care and baseline physical assessment to home care nurse as needed on discharge from acute care.

Rationale: Provides for continuity of care. May help reduce frequency of rehospitalization.

Discuss respiratory medications, side effects, adverse reactions.

Rationale: Frequently these patients are simultaneously on several respiratory drugs that have similar side effects and potential drug interactions. It is important that patient understand the difference between nuisance side effects (medication continued) and untoward or adverse side effects (medication possibly discontinued or dosage changed).

Demonstrate technique for using a metered-dose inhaler (MDI), such as how to hold it, taking 2–5 min between puffs, cleaning the inhaler.

Rationale: Although patient may be nervous and feel the need for sedatives, these can depress respiratory drive and protective cough mechanisms. Note: These drugs may be used prophylactically when patient is unable to avoid situations known to increase stress or trigger respiratory response.